Daily Archives: April 25, 2005

Patient Presentation A 10-year-old female came to clinic with “swelling in her armpit.” She was healthy except for eczema flares, but noted the swelling about 6 days ago and it is described as somewhat painful. She also had a low grade fever about the same time.
On her review of systems she had no weight loss, night sweats, or malaise. She did have some red bumps on her arm recently that were bigger than her normal eczema flares. She has no recent travel history, she has a pet cat and guinea pigs at school.
The pertinent physical exam shows normal vital signs and growth parameters. She has shoddy anterior and inguinal adenopathy. She has a 1.5 cm solitary left axillary node that is firm, and mobile with minimal overlying induration and pain. She has a mild lichenified rash medially on her elbow that is somewhat excoriated, red and raised appearing. The rest of her examination is normal.
The patient was treated for mild impetigo with Cephalexin antibiotic. After 2 weeks she returned and the axillary lymph node had not decreased in size. She had no fever and the impetigo had resolved.
The work-up at that time included complete blood count which showed a white blood cell count of 14 X 1000/mm2, erythrocyte sedimentation rate of 15 mm/hr and liver function tests which were normal. Additionally she had a tuberculosis skin test placed that was negative. An immunofluorescence antibiody assay eventually returned positive for Bartonella henselae and the diagnosis of Cat Scratch Disease was made.
She was treated with Azithromycin antibiotics and was to return in two weeks for re-evaluation.

DiscussionCat Scratch Disease is caused by Bartonella henselae, a slow-growing, gram-negative bacillus. It commonly occurs in people younger than 20 years of age. Cats are common reservoirs especially kittens. Cat fleas transmit the organism between cats but there is no known person-to-person transmission.
Diagnosis is generally made by immunofluorescence antibody. Treatment is primarily symptomatic with resolution usually within 2-4 months. Antibiotics may speed resolution, but painful supprative nodes may need drainage for relief.

Almost everyone has a few palpable lymph nodes at any time. Palpable lymph nodes are normal in anterior cervical, axillary and inguinal regions in healthy children.Lymphadenopathy is enlargement of the lymph nodes beyond this normal state. Practically this is any node >1.0 cm in greatest diameter, but certain nodes should be considered enlarged at different sizes (i.e. epitrochlear nodes > 0.5 cm, inguinal nodes > 1.5 cm, submandibular nodes > 1.5 cm).
The history and physical examination are particularly important in determing the differential diagnosis and ultimately the timing, workup and treatment of lymphadenopathy.

Learning Point
When should lymphadenopathy be evaluated depends on the history, physical examination, differential diagnosis, level of suspicion of serious underlying pathology and the anxiety of the patient, parent and health care provider. There is not one single approach.

The evaluation of lymphadenopathy may include a number of tests as indicated by the history, physical examination, differential diagnosis, index of suspicion and the anxiety of the patient, parent and health care provider.
These may include:

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